Healthcare Provider Details

I. General information

NPI: 1376904417
Provider Name (Legal Business Name): MANDAL'S CONSERVATIVE NEPHROLOGY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ZEAGLER DR
PALATKA FL
32177-3883
US

IV. Provider business mailing address

800 ZEAGLER DR
PALATKA FL
32177-3883
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-8158
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME0074439
License Number StateFL

VIII. Authorized Official

Name: DR. ANIL KUMAR MANDAL
Title or Position: OWNER
Credential: M.D.
Phone: 904-305-1234